Instruments used to assess gender-affirming healthcare access: A scoping review

Purpose The overall aim of this scoping review was to identify, explore and map the existing literature pertaining to healthcare access for transgender and non-binary individuals. Design The scoping review followed Arksey and O’Malley’s methodological framework, and the reporting adhered to the guidelines provided by the PRISMA Extension for Scoping Reviews. Methods To gather relevant articles, a comprehensive search strategy was employed across four electronic databases, with the assistance of a university librarian. In addition, manual and internet searches were conducted for grey literature. From the initial search, a pool of 2,452 potentially relevant articles was retrieved, which was supplemented by an additional 23 articles from the supplemental search. After an independent review by two researchers, 93 articles were assessed, resulting in the inclusion of 41 articles in the review. Results The literature highlights the identification of barriers and enablers, spanning across 32 individual data sets that affect healthcare accessibility for transgender and non-binary individuals. Leveque’s five dimensions of healthcare access, namely approachability, acceptability, availability and accommodation, affordability, and appropriateness, were utilized to categorise these 42 factors. Some of the key themes that emerged in these dimensions include challenges in accessing information about services, concerns about acceptance from family and peers, past experiences of discrimination in healthcare settings, considerations related to cost and insurance, and the difficulty in finding appropriately trained competent providers. Conclusions The review focused on the most commonly researched aspects of healthcare access and identified gaps in research and opportunities for future studies. The findings provide recommendations for policy and practice, which could guide the development of interventions aimed at addressing the barriers faced by transgender individuals seeking gender-affirming care.


Introduction
Transgender and non-binary individuals face significant challenges in accessing genderaffirming healthcare.Studies have consistently shown that this population experiences higher rates of discrimination and stigma in healthcare settings, which can result in decreased access to care and adverse health outcomes [1][2][3].
Furthermore, many healthcare providers lack knowledge of and training in transgender healthcare, which can result in inadequate or inappropriate care [4].This is particularly concerning for transgender and non-binary youth, who may be at particular risk for adverse outcomes such as depression, anxiety, and suicide [5].
Addressing these barriers to healthcare access is critical in promoting the health and wellbeing of transgender and non-binary individuals.The care provided should be tailored to each individual's specific needs, and will often include medical interventions such as hormone blockers, cross-sex hormones, and surgical procedures [6].
Healthcare navigation can be a significant challenge for transgender individuals and this is evident in media representation and through research.Therefore, this study aims to explore access to gender-related healthcare, particularly how healthcare is assessed in this population, by using Levesque's healthcare access theory [7].The choice of Levesque's healthcare access htheory is justified in this study because it takes into account the complex and multifaceted nature of healthcare access, encompassing various factors at both individual and system levels.It recognises that healthcare access is not only influenced by the availability and affordability of healthcare services but also by individual characteristics, such as socioeconomic status, cultural beliefs, and health literacy.Furthermore, it acknowledges that healthcare access is not a static phenomenon and may change over time due to various factors such as policy changes, social norms, and healthcare delivery models.
This theory has been used in previous studies examining healthcare access for marginalized populations, including transgender and non-binary individuals [8,9], and provides a useful framework for identifying and addressing barriers to healthcare access in this population.By applying this theory to a scoping review of healthcare access instruments for transgender individuals, the study could identify gaps in existing measures and inform the development of more comprehensive and inclusive instruments.
A scoping review is the most appropriate type of review in this case because it allows for a comprehensive exploration of the existing literature, which is essential in identifying the range of healthcare access instruments used and the influencing factors on access in the transgender population.Ultimately, this scoping review can contribute to the development of more effective strategies to promote equitable access to gender-affirming healthcare for transgender individuals.
The overall aim of this scoping review is to identify, explore and map the existing literature pertaining to healthcare access for transgender and non-binary individuals.
Specifically, the objectives of this scoping review are to: • Determine the types of instruments or tools used to evaluate healthcare access among transgender and non-binary individuals seeking gender-affirming care.
• Compare the geographical distribution of these assessment tools.
• Identify the theories that underpin the research in this field.
• Determine the most commonly reported challenges faced by transgender and non-binary individuals when navigating healthcare systems.
• Describe the standard methodological approaches utilized in the research, including study design and outcomes.
• Identify any gaps or areas where further research is needed.
This scoping review will systematically compare quantitative instruments employed in the assessment of healthcare access among transgender and non-binary individuals, establishing itself as the first of its kind.This distinctive approach holds significance for several reasons: firstly, it offers a comprehensive overview of key factors influencing healthcare access; secondly, it applies an established healthcare access theory to this specific population; and thirdly, it compares the factors influencing healthcare access in adult and youth cohorts, providing valuable insights into diverse perspectives and experiences.

Review design
This scoping review was conducted using the methodology described by Arksey and O'Malley (2005) [10], which was further improved by Levac et al. (2010) [11] and the Joanna Briggs Institute (2015) [12].The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) recommended by Tricco et al. (2018) [13].The scoping review protocol was developed and reviewed by healthcare access experts based in Ireland, as described in Kearns et al. (2023) [14].

Identification of research question
The first stage of this research involved identifying the research question through an initial literature review and consultation with clinicians and an expert panel of transgender and nonbinary youth.The resulting research question was:

What factors help and hinder access to gender-related healthcare and how are these factors identified by quantitative instruments?
As researchers with backgrounds in providing transgender healthcare, we acknowledge that our experiences in clinical settings and academic environments have shaped our understanding of the challenges faced by transgender and non-binary individuals in accessing healthcare.Three of the authors actively work in providing transgender healthcare services, bringing a practical and applied perspective to the study.The final author, a nursing lecturer and module developer, contributes an academic viewpoint to the research.
Furthermore, we recognize the importance of our own identities, including some of us identifying as members of the LGBT community, in influencing our approach to this study.These experiences contribute to our commitment to inclusivity and understanding the unique healthcare needs of transgender and non-binary individuals.
Regarding the expert panel consisting of youths, the participants were young adults aged between 18 and 30 years old.They were intentionally recruited through maximum variation selection to ensure diverse experiences in accessing services as both youth and adults.This decision was made to enrich the study with a range of perspectives and insights into the evolving challenges faced by transgender and non-binary individuals throughout different stages of life

Identification of relevant studies
The study employed a systematic search strategy that involved four electronic databases; Psy-chINFO, CINAHL, Medline, and Embase.The databases were selected based on their relevance to the topic under investigation.The search strategy was formed with the assistance of a University librarian, in accordance with the recommendation of McGowan et al. (2020) [15].The search was completed for all available literature up until December 2022.
The study protocol [14] contains a sample search strategy and inclusion-exclusion criteria.The search terms were guided by the PCC (Population, Concept, Context) mnemonic, as outlined by Peters et al. (2020) [16], and synonyms relating to the PCC were identified and utilized.The identified population in this study were transgender and non-binary individuals seeking gender-affirming care and included search terms such as 'transgender' OR 'nonbinary' OR 'gender dysphoria', the concept is a healthcare accessibility instrument and included search terms such as 'quantitative' OR 'survey' or 'questionnaire', and the context is gender-related healthcare access and included search terms such as ' healthcare' OR 'health' OR 'gender care' OR 'hormones'.Each strategy was modified to meet the database-specified requirements for MeSH headings, Boolean operators, and truncation markers.
In addition to the electronic database search, the study team conducted a hand-search of the reference lists of included studies.A grey literature search was also conducted to identify potentially overlooked studies that meet the inclusion criteria and because it is a requirement for rigour in scoping reviews.This search was completed using "Google Scholar" and web searches, and the first one hundred results from identified keywords were assessed for eligibility.The PRISMA Flowchart (Fig 1) details the results obtained from the electronic database and grey literature searches.

Study selection
Studies were screened using the Rayaan screening software, which facilitated the management of data by enabling the upload of studies.This software was particularly helpful in eliminating duplicates (n = 1338).Subsequently, title and abstract screening was carried out by two authors, SK and PH, with a third author, DOS, available to address any conflicts that arose.Initially, the two main reviewers conducted an independent screening of 50 articles against the study's inclusion and exclusion criteria, and inter-rater reliability was assessed.
The pilot of 50 studies demonstrated high inter-rater reliability, and consequently, 2,452 titles and abstracts were screened, resulting in the identification of 74 studies for full-text screening.No adaptations were required following the pilot.The full-text screening was conducted by SK, PH and KN, and 36 studies were included.The grey literature was evaluated by SK and KN through website searches, organizational reports, and reference lists of included studies, leading to the inclusion of 5 additional studies.

Charting the data
An Excel sheet was utilized to extract data for the study, with agreed-upon headings that matched the research question and objectives (refer to Table 1).The data was not evaluated for quality, which is typical for scoping review methodology.Nevertheless, the data was collated, and the overall findings were narratively described in the results section.These results were shared through a in-person group discussion with a pre-existing expert panel consisting of transgender and non-binary youths who confirmed that the results were consistent with their personal experiences.

Results: Collating, summarizing and reporting
Results from the database and grey literature search are show in the PRISMA diagram below (Fig 1 ).A final list of 41 records met all the eligibility criteria.

Study characteristics
The review includes a total of 41 records that represent research from 18 countries across 5 continents, namely Asia, Australia, Europe, North America, and South America.The United States has the highest number of publications in this field (n = 22), followed by Canada (n = 6), Europe (n = 5), Asia (n = 4), Australia and New Zealand (n = 2), and South America (n = 2).The European studies represent nine countries, while Asia and South American studies represent three and two countries, respectively.The studies were conducted in twelve high-income countries, five upper-middle-income countries, and one lower-middle-income country.
These 41 records represent 32 individual data sets, with five studies sharing a data set from the United States [17][18][19][20][21], two studies sharing a data set from Germany [22,23], and two studies sharing a data set from Korea [24,25].Half of the studies were published in the last four years (n = 21), while the earliest study was conducted in 2008 (n = 1).Fig 2 shows the number of included studies per year.All of the 41 studies utilized cross-sectional study designs.A majority of these studies were conducted online (n = 27/41), while six studies recruited participants from clinics, three studies recruited in-person, and four employed a combination of  • Most of the participants received information about GAS from transgender websites and transgender surgery clinics (91% and 50%, respectively).
• Most participants (74%) felt like they had access to appropriate care and 89% felt like their surgeons provided enough information about GAS.
• Surgical transition was important to the quality of life for 91% of participants and 100% were happy with their decision to undergo GAS.

Germany, Hamburg
Trans/NB (n = 425) Age: 16+ • Transmen were most likely to avoid healthcare following discrimination than their counterparts.
• Transgender participants who experienced discrimination "only due to their transgender identity" and due to "their transgender identity and other reasons" reported a 1.91 and • Very few used silicone or surgeries as part of their gender-affirmation process.
• Only 5.4% of participants reported that they had access to hormones through a health professional and 2.1% reported that they had access to them from another transgender person.
• A small number of participants (N = 3) reported having had surgeries.
• The frequency of discrimination varies from • Also, a significant share expressed the feeling that they had to convince their provider they needed care and/or express their wish in such way to increase their likelihood of receiving care.

Theoretical underpinnings
The Minority Stress Theory (MST) is the most frequently cited theory in the literature (n = 9), with included studies employing this framework to design quantitative instruments.Even when not explicitly mentioned or stated, the influence of MST is apparent in the included studies.The theory posits that individuals belonging to minority groups experience higher levels of external/distal stressors, such as prejudice, rejection, and discrimination, which can lead to internal/proximal stressors, including concealment of one's identity, internalised homophobia/transphobia, and hypervigilance and anxiety related to prejudice/victimization.These factors can negatively affect health status and healthcare utilization.Therefore, many of the included articles focus on experiences of discrimination, harassment, victimization, peer support, and current mental health and self-esteem status.
In addition, one of the included studies noted the relevance of Ansara's cisgender theoretical framework [31], which examines cisgenderism and how clinicians often wrongly assume gender, and this causes negative experiences of clinical care [32,33].While healthcare access theories are infrequently referenced in the literature, one study [9] mentions Levesque's healthcare theory (2013) [7].However, other healthcare access theories such as Pechanskay and Thomas (1981) [34], Andersen (1995) [35], or Ryvicker (2018) [36] are not mentioned.These healthcare access theories were considered for this review as a theoretical framework but Levesque's healthcare access theory was specifically chosen for this paper due to its structured approach and clear categories.This proved invaluable in the organization and analysis of a large data set for this scoping review.As the study aimed to explore a broad range of factors within the literature, the authors found that Levesque's framework provided a systematic and comprehensive foundation, enhancing the ability to discern and categorize various factors influencing healthcare access for transgender and non-binary individuals.The theory's consideration of individual and systemic factors, including socioeconomic status, cultural beliefs, and health literacy, allowed for a detailed exploration of the challenges faced by this population.Moreover, its recognition of the dynamic nature of healthcare access, influenced by policy changes, social norms, and healthcare delivery models, made it particularly suited for examining the evolving landscape of transgender healthcare.

Design and development of instrument (Patient and public involvement [PPI])
Patient and public consultation were common in the included studies, even though they were quantitative in nature.Almost half of the studies (n = 19) included some form of patient and public involvement.From these nineteen studies, five data sets were derived from the same American sample of patients [17][18][19][20][21], and two of the nineteen data sets came from the same German sample [22,23].Therefore, fourteen unique data sets included different PPI strategies as part of their quantitative methodologies (n = 14).These are described in Table 2.
The most common form of patient and public involvement was the development of an expert panel or advisory group of transgender and gender diverse individuals (n = 7) who met at timed intervals throughout the project.The next most common was consultation with transgender and gender diverse individuals (n = 5) and was normally not described as recurrent.
Caregivers, parents and LGBT advocacy groups were sparingly utilized for their expertise and healthcare providers were the most underrepresented as advisory stakeholders (n = 1).

Factors influencing healthcare navigation
The present study has identified a total of forty-one distinctive factors that can either facilitate or impede healthcare access to gender care based on a comprehensive review of the included studies.These factors have been systematically classified and charted according to Levesque's (2013) five dimensions of accessibility, namely: 1) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness.A detailed account of the charting and categorisation of these factors is provided in S1 Data.All studies were included for the initial analysis.Notably, this paper has highlighted the top 25 factors which are presented in Fig 3.
Regarding approachability, the most significant factor identified was the lack of service information, as indicated in thirteen of the studies [25-29, 38-39, 41, 46-50].Transgender and gender diverse individuals encountered difficulties in sourcing accurate information about service availability and the available interventions.Furthermore, the pathways to access these services were frequently perceived as difficult to navigate or comprehend, as evidenced by (n = 6) studies [26,27,38,41,47,48].
Acceptability is determined by cultural and societal factors that dictate whether people are willing to accept certain aspects of care and whether seeking care is deemed appropriate for them.This category prompted the most factors related to accessing care.The present study examined the impact of previous experiences of discrimination on healthcare-seeking behaviours among a sample of individuals across eighteen studies [20, 24, 26, 37-38, 40-43, 45, 47, 48, 50-55].Findings indicate that discriminatory behaviours, such as invasive questioning, denial of care, incorrect name and pronoun use, and inappropriate physical exams, were associated with decreased likelihood of seeking future healthcare needs.
Furthermore, the study identified differences in the ease of access to care among gender identity groups in seventeen studies [17-21, 23-25, 37, 38, 44, 45, 48, 49, 56-58], with distinct disparities observed between transfeminine and transmasculine individuals and between binary and non-binary healthcare seekers.One notable disparity highlighted in the study is that a higher proportion of binary individuals demonstrated greater access to healthcare compared to their non-binary counterparts.Additional disparities were observed, including variations in access to surgery between transmasculine and transfeminine individuals, as well as discrepancies in access related to ethnicity or race.These results suggest that cultural and societal values and norms may profoundly influence healthcare behaviour across these groups.Importantly, this dimension highlights the critical role of support and acceptance from family and peers in influencing healthcare access in twelve of the included studies [25, 26, 28, 29, 37, 39, 41, 44-46, 49, 57].
Lastly, the appropriateness of services was evaluated based on the congruence between services provided and the client's needs, as well as the quality of care received, including the interpersonal aspects of the care process.Findings from the studies revealed that participants frequently perceived healthcare professionals as lacking adequate skills or knowledge to deliver care, resulting in the patients needing to educate their providers (n = 21) [20, 26-30, 38-42, 45, 46, 48, 50-52, 55, 56, 59, 61].Furthermore, a considerable number of participants viewed mental health assessments as a redundant barrier to care (n = 11) [22, 25, 28-30, 40, 41, 47, 52, 57, 59].

Youth and accessing gender related healthcare
Eight studies were included in this analysis, involving participants under the age of 16, with the youngest child being 4.7 years old [9,30,31,44,46,49,51,53].The majority of studies originated from North America, with three from the United States and three from Canada.One study each was conducted in Mexico and Australia.
Of the Canadian studies, one cross-sectional study focused on healthcare access and comfort of care in primary care and gender services, which recruited individuals aged 14 and above.The remaining two Canadian studies recruited through interdisciplinary gender clinics specializing in gender care for young people.Of the American studies, one study recruited from a specialized gender clinic in Manitoba, while another study assessed the needs and experiences of non-binary youth through a cross-sectional study.
One study focused on access to top surgery in Boston and included participants aged 15 and above.Lastly, one study focused on discrimination and violence in Mexico and included children aged 14 and above, while one Australian study assessed the perspectives of transgender and gender diverse young people accessing gender care between the ages of 14 and 25.
A total of 22 unique factors were identified as issues facing youth in accessing gender care (See Fig 4).A detailed account of the charting and categorisation of these factors is provided in S1 Data.Waiting times were the most commonly referenced issue, highlighting concerns around availability and accommodation.Acceptance and support from family and peers were identified as key factors in the acceptability dimension.Feelings of fear and uncertainty were also commonly reported, with some youth unsure whether they wanted or needed medical interventions to affirm their gender.The age of seeking care was noted as an important factor, and the challenges of finding competent providers persisted across all age groups.Although financial cost and affordability concerns were mentioned, they were not considered to be as significant as other issues.Nevertheless, opinions regarding appropriateness were frequently expressed, with many young people and parents commenting on the lack of provider expertise and ability to meet their needs.
The authors observed that non-binary identities and gender diversity were more prevalent among younger cohorts, and that there were varying models of care, with specialised gender clinics playing a crucial role in providing care.

Discussion
Access to gender-affirming care is a critical issue for transgender people, who often face significant barriers to accessing the care they need.This is the first scoping review to compare the quantitative instruments used to assess healthcare access among transgender and gender diverse individuals across 32 individual datasets in 41 papers.
In order to provide a more comprehensive understanding of these findings, our study applied identified factors to Levesque et al.'s (2013) five dimensions of healthcare access: approachability, acceptability, availability and accommodation, affordability, and appropriateness.
Approachability refers to the ability of a person to identify and reach a healthcare service.Our review found that transgender people may not be aware of the healthcare services available or may lack accurate information about their options for gender-affirming care.To improve approachability, healthcare providers and policymakers should work to increase awareness and education around available services and provide clear and accurate information about the benefits and risks of different treatment options.
None of the studies included in this review assessed health literacy, which the authors believe would be a novel area of investigation for future research.Furthermore, examining the impact of co-occurring diagnoses on approachability is not fully understood, and should be a priority of future research.
Acceptability refers to the ability of a person to seek care without experiencing discrimination or judgment.Our review found that transgender people may face significant barriers to seeking care, including fear of discrimination or stigma, lack of trust in healthcare providers, and lack of support from parents and peers.A supportive family is particularly important to younger patients.
To improve acceptability, healthcare providers can create welcoming and supportive environments for transgender patients and work with families in increasing understanding of gender related needs.In addition, policymakers can work to address discrimination and stigma in the healthcare system.Given the current political climate in some parts of the world, where lawmakers are enacting policies that restrict healthcare access for transgender individuals, it is likely that the acceptability dimension of healthcare access may be threatened.
In light of these findings, further research on protective factors, and in particular the role of family/peer support as enablers to accessing healthcare services, would be useful.Furthermore, an examination of the role of internalised transphobia in deferring seeking care would be an interesting research aim for future studies.
Availability and accommodation refer to the ability of a person to find and access healthcare services.Our review found that transgender people may face geographic or financial barriers to accessing gender-affirming care, particularly in areas where there are limited healthcare providers or services.To improve availability and accommodation, policymakers can work to ensure that healthcare services are available and accessible to all individuals, regardless of their location or financial status.This may include considerations of various models of care and the manner in which healthcare services are provided, which may differ based on the level of national resources available and political favour in funding services.
In countries where lengthy waiting lists represent a significant barrier to accessing healthcare services, it may be advantageous to introduce pilot interventions that provide information and support to prospective clients and their families while they wait to be seen.Additionally, given the growing interest in telehealth as a means of delivering gender services, it would be valuable to assess provider and patient perspectives on this approach.
Affordability refers to the ability of a person to pay for healthcare services.For transgender people living in regions were insurance coverage is needed to access healthcare, affordability can be a significant barrier.To improve affordability, healthcare providers and policymakers can work to ensure that gender-affirming care is affordable and accessible to all, regardless of ability to pay.This review found an oversaturation of research on the influence of cost and insurance on access to hormones.However, there is a dearth of research on experiences accessing surgical interventions and the effect of affordability on accessing surgery.
Appropriateness refers to the ability of a person to receive care that meets their individual needs and preferences.Our review found that transgender people may face significant barriers to engaging in the healthcare system for a variety of reasons, including lack of trust in healthcare providers, and mandatory mental health assessments.To improve appropriateness, healthcare providers can work to create individualised treatment plans that meet the unique needs and preferences of transgender patients while ensuring that the quality of clinical care is not jeopardised.
Furthermore, the review identifies opportunities for specialised healthcare services and providers to develop and implement training programs aimed at enhancing their proficiency in delivering gender-affirming care, as well as providing training to primary care providers to augment their knowledge in this area.
Patient and public involvement (PPI) is recognized as an advisory component in the conduct of research involving the transgender community.However, this review indicates that there is a dearth of detailed descriptions of the PPI processes employed, as well as a lack of information regarding sampling.While the study revealed that members of the transgender community were primarily involved in co-design, the inclusion of other key stakeholders was infrequent.It is recommended that future research incorporate nuanced PPI approaches to enhance the quality of research and report their involvement in a transparent manner.
The studies included in this review describe a diversity of gender affirming care access points, ranging from primary care providers, specialised gender clinics, telehealth services, or via non-prescribed methods such as obtaining medications from friends.This diversity of pathways poses challenges to research analysis, as there is no universal standard for accessing gender-affirming care.In addition, the differences in approach also makes it difficult to generalise results or experiences outside of the country and context that they are conducted in.
The review highlights that primary care access is more frequently observed in North America for adults, while gender clinics are more prevalent in Europe.Specialised gender clinics are more common for children and teenagers across the world.This poses an interesting question as to why the model of care changes so drastically from adolescence to adulthood when the complexity of need likely remains unchanged.

Strengths and limitations
This paper has several strengths that enhance its contribution to the field.Firstly, it provides a comprehensive overview of the key factors influencing healthcare access for transgender and gender diverse individuals.Secondly, the study utilises an established healthcare access theory and systematically applies it to this population.
Additionally, the research compares the factors influencing healthcare access in adult cohorts versus youth cohorts, which adds a valuable perspective to the findings.The study team included medical and nursing professionals, demonstrating a united approach to the research objective.The clinicians involved have expertise in gender care, and an expert panel of transgender and gender diverse youth was consulted throughout the project, further enhancing the study's rigour and relevance.
However, this review has noteworthy limitations.Firstly, we employed a systematic approach to searching and screening relevant publications in four databases for this review and through grey literature searches, but our results are limited by the sensitivity of our search strategy and databases.
Secondly, the included research primarily represents the perspectives of transgender and non-binary individuals, with little input from clinicians who specialise in gender care or family members who may be important stakeholders in accessing care for individuals.Future research would benefit from examining the perspectives of multiple stakeholders.Additionally, this review does not provide a clear definition of what constitutes appropriate care and whether this definition varies between healthcare professionals, patients, and their families.
Thirdly, most of the studies included in this review utilized online samples, which could result in selection bias and non-representative samples, despite the benefit of large sample sizes.
Lastly, youth were underrepresented in this sample, with only eight papers including their perspectives.We conducted a sub-analysis of factors identified from youth-only studies, but the results are limited by the small number of studies and small sample sizes.It would be valuable to compare the factors influencing healthcare access between youth and adults in a specific geographic context, with a focus on the different aspects of healthcare access as described by Levesque.

Conclusion
In conclusion, this scoping review highlights the importance of Levesque et al.'s (2013) theory of access to healthcare in understanding the barriers faced by transgender people in accessing gender-affirming care.By examining the abilities of transgender people to perceive, seek, reach, pay, and engage with healthcare services, this review provides important insights into the factors that influence access to gender-affirming care for transgender people.
Though transgender and non-binary representation has increased in the media, there still exists many obstacles to accessing care in each dimension of Levesque's model.The findings of this review provides recommendations for practice and policy, and could be used to inform the development of interventions and policies that address the barriers faced by transgender people in accessing gender-affirming care.Ultimately, by improving access to gender-affirming care, healthcare providers and policymakers can help to improve the health and well-being of transgender people and ensure that they receive the care they need to live healthy and fulfilling lives.

Table 1 .
(Continued) • Youth were worried about talking to healthcare providers as they were concerned as to the questions they would be asked, the lack of support they would get and felt services were not supportive of LGBT health.